Tag: PTSD

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Forewarned is forearmed: First Responders and Traumatic stress

The ancient Latin saying, ” Praemonitus, praemunitus,” later in 16th century England became “Forewarned is forearmed” can apply to a wide variety of situations. For this post I’ll be discussing the importance for first responders to learn about the potential dangers of their work to their mental health.

Before I begin it is important to note that each individual will process their experiences differently. Not everyone who is exposed to a traumatic event will end up with a traumatic stress related injury. Advance knowledge of Post Traumatic Stress Disorder (PTSD) and related disorders can help first responders help themselves and their co-workers.

Post Traumatic Stress Disorder (PTSD) is fully explained on the website of the National Institutes of Mental Health. I encourage all first responders to read the information on their site.

For the purpose of this entry I share the criteria the NIMH list on their site for a diagnosis of PTSD below. In the last paragraph the BOLD type was added by me for emphasis:

“To be diagnosed with PTSD, an adult must have all of the following for at least 1 month:

  • At least one re-experiencing symptom
  • At least one avoidance symptom
  • At least two arousal and reactivity symptoms
  • At least two cognition and mood symptoms

Re-experiencing symptoms include:

  • Flashbacks—reliving the trauma over and over, including physical symptoms like a racing heart or sweating
  • Bad dreams
  • Frightening thoughts

Re-experiencing symptoms may cause problems in a person’s everyday routine. The symptoms can start from the person’s own thoughts and feelings. Words, objects, or situations that are reminders of the event can also trigger re-experiencing symptoms.

Avoidance symptoms include:

  • Staying away from places, events, or objects that are reminders of the traumatic experience
  • Avoiding thoughts or feelings related to the traumatic event

Things that remind a person of the traumatic event can trigger avoidance symptoms. These symptoms may cause a person to change his or her personal routine. For example, after a bad car accident, a person who usually drives may avoid driving or riding in a car.

Arousal and reactivity symptoms include:

  • Being easily startled
  • Feeling tense or “on edge”
  • Having difficulty sleeping
  • Having angry outbursts

Arousal symptoms are usually constant, instead of being triggered by things that remind one of the traumatic events. These symptoms can make the person feel stressed and angry. They may make it hard to do daily tasks, such as sleeping, eating, or concentrating.

Cognition and mood symptoms include:

  • Trouble remembering key features of the traumatic event
  • Negative thoughts about oneself or the world
  • Distorted feelings like guilt or blame
  • Loss of interest in enjoyable activities

Cognition and mood symptoms can begin or worsen after the traumatic event, but are not due to injury or substance use. These symptoms can make the person feel alienated or detached from friends or family members.”

It is natural to have some of these symptoms for a few weeks after a dangerous event. When the symptoms last more than a month, seriously affect one’s ability to function, and are not due to substance use, medical illness, or anything except the event itself, they might be PTSD. Some people with PTSD don’t show any symptoms for weeks or months. PTSD is often accompanied by depression, substance abuse, or one or more of the other anxiety disorders.“

I added the bold type above to emphasize the fact that feeling off or experiencing any of the reactions listed above immediately after a traumatic event is normal. The phrase often used is, “It is normal to feel abnormal .” If the reactions do not lessen after a month or so, that is a sign to seek additional support from a therapist or doctor.

First responders, like service members, often hesitate asking for help. No one wants to be taken off of active duty, or to say they are struggling. Fortunately in the military great strides are being made in de-stigmatizing asking for and seeking help. Due to increased awareness of suicide rates among first responders, steps are now being taken by public safety administrators to increase peer support programs and enhance employee assistance programs. More work need to be done in this area.

Administrators of public safety departments need to lead in the realm of education on mental healthcare for their department.

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What is Traumatic Stress

Thanks to the public information campaigns of a number of organizations supporting veterans the term PTSD, or Post Traumatic Stress Disorder is now widely known. After almost 20 years of learning and lecturing about PTSD I have learned that while the name is well known there is still very little general understanding of the criteria a person has to meet to be given the diagnosis of PTSD.

Several years ago a chaplain friend of mine asked me to speak to the oncology department at his hospital. The topic was traumatic stress and self care. The nurses attended the didactic thinking they were there to learn how to care for their patients who may be traumatized. What my friend guessed and what I learned after this experience is that some of the nurses experience and struggle with the traumatic events they deal with in the course of their work.

What I wrongly assumed is that medical professionals would know and understand the toll their work takes on them personally, they did not. That lecture led to an invitation to another conference of medical professionals. In the three years I’ve served as a chaplain for the Roswell Fire Department I’ve had conversations about traumatic stress with our public safety employees in the fire, police and 911 dispatch areas. Many know their jobs expose them to trauma, but few know what it takes to meet the criteria for a PTSD diagnosis.

For a comprehensive explanation of PTSD you should read through the National Institute of Mental Health web page on Post Traumatic Stress Disorder. In summary there is a list of conditions that must be present to meet the criteria for a diagnosis. After experiencing or witnessing a traumatic event it is normal to feel unsettled, upset and have trouble processing the experience. If after a month or two after an event, or after responding to a number of disturbing events in the case of public safety personnel, you are struggling with symptoms that interrupt your normal ability to function, you should seek help from a professional trained to diagnose and help people who experience traumatic events.

Much has been done in this field the past 20 years. Therapies have shown to greatly reduce the symptoms of traumatic stress and allow the person with the diagnosis to function at a very high level. There is such a high success rate that professional in the field are working to change the name from Post Traumatic Stress Disorder to Post Traumatic Stress Injury. The word disorder has a connotation that it is a pre-existing condition where as the word injury more correctly fits the symptoms since we now know people can recover and heal from their experiences. In a letter to the American Psychiatric Association, Drs. Frank Ochberg and Jonathan Shay outline their reasoning for the change from disorder to injury. I encourage you to go to the website, Post Traumatic Stress Injury, and read through the various links.

I do need to mention that I look to Dr. Ochberg and Dr. Shay as mentors in the field of traumatic stress. I had the opportunity to meet both in 2003 at the International Society of Traumatic Stress Studies. Both are very generous with their time and knowledge and helped me learn early after I graduated from seminary about traumatic stress and related diagnosis. I have had the opportunity to attend a few other meetings over the years with both doctors, and others like Dr. Charles Figley who wrote the book on Compassion Fatique. You will note several resources on the Resources for First Responders entry are related to these three doctors.

For an easy to understand, and listen to, webcasts about PTSD and related topics, see this webpage from Gift From Within .

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Resource List for First Responders

This list will be updated as I learn of other reputable resources for first responders and others interested in learning more about PTSD, traumatic stress, and related topics. Since the major research area for PTSD is the military many of the resources are under the VA, but the information is applicable to most people with a traumatic stress diagnosis.

NOTE: I receive no compensation from the following organizations. They are listed as a resource only. The information here is not meant to replace a diagnosis from a licensed mental health professional.

  • Helplines:
  • Fire/EMS Helpline: 1-888-731-3473
  • Safe Call Now: 1-206-459-3020
  • FBHA: 847-209-8208
  • COPLINE: 1-800-267-5463
  • Nat’l Suicide Hotline: 1-800-273-8255

National Center for PTSD – “The National Center for PTSD conducts research and provides education on the prevention, understanding and treatment of PTSD.”

On Facebook: National Center for PTSD – U.S. Department of Veterans Affairs

PTSD Decision Aid from the National Center for PTSD

VA screening tools (confidential) for PTSD, Depression, Substance Abuse, Alcohol Use

National Institute of Mental Health – Post -Traumatic Stress Disorder read the information on this link for a listing of signs and symptoms, risk factors, treatment and therapies.

Firefighter Behavioral Health Alliance – Self Assessment – a self-screening for suicide ideations for firefighters/EMT

International Association of Firefighters – IAFF Behavioral Health Program

Next Rung Website – “We are a nonprofit with a mission to combat mental health issues in First Responders by offering peer support and scholarships for licensed counseling.” Next Rung on Facebook

PTSD in Paramedics, EMTs, First Responders on Facebook – “You no longer have to suffer in silence, you are not alone. We are here to help.” Website: Project Hope: EMS

Compassion Fatigue: Figley Institute

Trauma support: Gift From Within – An international nonprofit organization for survivors of trauma and victimization. Gift From Within Free webcasts

Confidential online screening for mental health issues – from, The Summit Counseling Center, North Fulton County, GA

Mission FISH USA – “The Purpose of Mission FISH., FISHING, INTERACTING SHARING & HEALING  is to organize and plan fishing day trips and provide FISH therapy for PTSD and TBI for Veterans, Active duty service members, 1st responders and Gold Star families.”

Reboot Recovery – “REBOOT is different. Our courses are led by people who have been there, lived through it, learned from it, and want to help lead others out of it. We are a community of people committed to helping each other heal from the spiritual and emotional impact of daily stress and trauma. You won’t find shortcuts or easy answers but rather solutions that last. Families just like yours are experiencing healing at this very moment. Your healing can start today.”

Save a Warrior – Save A Warrior™ has changed countless lives through our “War Detox” program, which supports the healing from Post-Traumatic Stress (PTS). We specialize in connecting Active Duty Military, Returning Veterans, and First Responders experiencing psychological trauma. 

Suicide prevention:

Suicide Prevention Lifeline

Suicide Prevention Resource Center

Suicide prevention workshops:

Soul Shop Movement

Armed Forces Mission – 911

Books:

Achilles in Vietnam: Combat Trauma and the Undoing of Character

Compassion Fatigue: Coping With Secondary Traumatic Stress Disorder In Those Who Treat The Traumatized

Odysseus in America: Combat Trauma and the Trials of Homecoming

Resilience: The Science of Mastering Life’s Greatest Challenges

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Relieving stress: Push ups or coloring books

A recent article in the Free Beacon caused an uproar among cadets and graduates of senior military colleges. The author of the article wrote about the practice at VMI of offering exam time stress relief activities. One of the activities open to the students is the use of coloring books. The idea that future military officers would be encouraged to use a typical childhood activity was offensive to many who read the article. Social media lit up the day the article was published and days later it si still being discussed.

As a former chaplain resident at the Atlanta VA Medical Center I found the negative comments around this activity offensive. Art therapy is a recognized modality to help veterans who have a diagnosis of Post Traumatic stress disorder and related anxiety issues. Coloring sheets were readily available and used by the veterans on the psychiatric floor.

In July 2016 Jeremy Ramirez, BS, MPH-C wrote, A review of Art Therapy Among Military Service Members and Veterans with Post-Traumatic Stress Disorder for the Journal of Military and Veterans’ Health Volume 24 No. 2 His conclusion after reviewing the various modalities to help veterans including Cognitive Behavior Therapy (CBT) is:

Challenges of military service should be met with a supportive culture that is open to implementing art therapy as a treatment modality in addition to current evidence-based practices. This review suggests that if current service members and veterans were placed into art therapy programs as early as possible after being diagnosed with PTSD, they would be at less risk for developing greater PTSD symptom severity. The preferred method of treatment for patients with PTSD receiving care in the VA healthcare system is CBT, however, since CBT is effective in treating only two of the three symptom clusters, it is an incomplete care package. Given the effectiveness art therapy has in treating the third symptom cluster, it is not meant to replace CBT, but rather it is meant to be offered in addition to CBT in order to produce a more comprehensive care package for past and present service members with PTSD.

I have to wonder why anyone would object to future military officers learning proven techniques to help deal with stress which could eventually help lower the astronomical suicide rate of our veterans. Physical activities like push ups (#22PushUpChallenge) are acceptable but other methods to raise the awareness and/or to teach stress relief are put down. To help prevent suicides early lessons in stress relief a destigmatizing getting help are key.

Putting down efforts to help with stress only adds to the negative stigma already prevalent for mental health issues.

I think I’ll go color now. . .

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Advice from Dr. Frank Ochberg to Military Moms

I recently joined the Facebook group Army Moms. It has been helpful to read the posts of the members and learn what life is like when your child is deployed. The posts about returning soldiers are usually very upbeat, but one recent post hinted at the struggles the returning soldier is having with the things he saw and experienced while deployed.

For the past 10+ I’ve studied traumatic stress, but as my own son approaches his deployment to Afghanistan, I read these posts with a different eye than I did when I began to study trauma.

Some days I fight the lump in my throat and the tears that are sure to follow. On an intellectual level I understand that feeling abnormal after a traumatic event is normal. I know there are many wonderful therapists and doctors in the field to help our returning soldiers. I also know the terribly high suicides rates of our veterans. I know these brave warriors hesitate to ask for help when they return and struggle with thoughts that haunt them, and nightmares that live within them.

And I know that I am a mom of a soldier that needs to use all the strength I can muster to support my son.

Dr. Frank Ochberg, a psychiatrist and one of the founding fathers of modern psychotraumatology, is one of my mentors in the field of traumatic stress studies. I wrote to him after reading the heart wrenching post from the Army mom asking for help with how to support her veteran son.

Dr. Frank Ochberg addresses a session at the annual meeting of the Society of Professional Journalists.

I had already posted links to the National Center for PTSD and the nonprofit Gift From Within and wanted to know if he had any other helpful resources to recommend.

As always Frank wrote back with a very thoughtful response. His letter is one that all military families need to read BEFORE their soldier returns home. Military families need to do research before their soldier returns. The family should know the local resources available and the online resources so that when their soldier returns home the process of adjusting is understood.

Dear Mom of a young Service Member,

 We’re all in this together and it is good to realize that we have a large family of parents, friends, advocates, therapists, clergy, and others who care.  When your son says to you, “You don’t want to know,” I assume he is looking out for you.  He wants to spare you the images and the sounds and the smell of the place.  I’d thank him for that.  It is considerate of him.  And it doesn’t mean he thinks you are fragile.  Many of my patients, including those who know that I have heard hundreds and hundreds of trauma stories, try to spare my feelings.  They don’t want me to hurt for  them, and they don’t want to spread the horror that they have witnessed. When it feels appropriate, I might explain that I have learned how to listen without becoming damaged.  But it’s a fine line.  I can’t say I’m unaffected. I don’t want to suggest that these experiences are less profound and terrible than they really are.  So step one, I’d suggest, is to express gratitude for his kindness and caring.

 It is good for your son to have a person who can hear him out, a buddy or an older person who understands.  Odds are he already has such a person in his life.  You’ll feel reassured if you know that this relationship exists, and is being used appropriately.  He may be willing to let you know.  I’m very interested in the natural friendship network of my patients, and I do try to nurture good, supportive connections.  Not too long ago, I had two Marines come for sessions together. One was married, the other wasn’t.  There was a strong bond between the two.  They let it all out in front of each other and in front of me.  They kept most of this away from their closest family members –certainly their Moms. One had a military Dad and there was some sharing with him, but not all the detail.

 We have good evidence to suggest that Service Members who have “seen some really bad stuff,” as your son reports, do best when they use normal networks to sort out their feelings.  There is no need to think about mental heath professionals until and unless serious signs emerge.

These serious signs include nightmares and flashbacks persisting at least a month.  They include serious drinking and drugging.  They include shutting down and walling off from others so that family life and school or work are imperiled.  They include shifts in character to an alarming extent, including dangerous outbursts of anger.  Usually, this state of affairs can be avoided through peer support and healthy activity.  But exposure to deadly conflict can produce PTSD, depression and substance abuse.  So learning about those conditions is useful, for you, Mom.

Here is a page I have helped create. There are many, many more. Just go to Google, put PTSD Info in the subject line and have look.  Sharing insights and concerns with others in the military support network is useful, too.

 If your son does change his mind and chooses to tell you about his “bad stuff,” listen actively.  Don’t interrupt and don’t rush to reassure and comfort too quickly.  Here’s a good link on “active listening.” It isn’t easy to picture your son in harm’s way, or to realize that he may have been involved in lethal activity that causes him feelings of guilt and grief. I try not to say, “You have no reason to feel guilty,” or words to that effect.  I might say, “Feeling guilty is the burden of having a good character, a conscience.”

After some painful memories are shared, it helps to move to other topics.  But never too abruptly, giving the impression that you have heard enough and want to close him down.  It’s best for him to set the pace and the duration.  It’s best not to interrupt.  In a therapy session, I have to establish a time limit. So I do change the subject well before the end of the hour.  I ask about exercise or friends or family.  I lighten the subject, but keep it relevant.  You could do that, too, if the time together must end soon.

 Everyone is different, so there are few hard and fast recommendations.  You do want your son to feel comfortable being with you, knowing you love him, and trusting that you will honor his private experience of profound reality. You’ll know you are on target when he tells you, little by little, what he wants you to know.  You’ll know you are on the right track when the two of you have fun together.  You’ll know all is well as you see him move through those stages of transformation into adult life, with an occupation, a family, and friends who care.

Frank M Ochberg, MD

Frank

Most people do the equivalent of closing their eyes and hoping they never have to deal with the scarier parts of post deployment life. As hard as it may be to read some of the materials, being knowledgeable of the signs to look for, and how to best support your returning soldier , you can make the transition to civilian life easier for the soldier.

Additional resource links follow:

PTSD 101

Defense Centers of Excellence for Psychological Health & Traumatic Brain Injury

Military Family Network

Betty Clooney Center

About Face – “Learn about post traumatic stress disorder (PTSD from Veterans who live with it every day. Hear their stories. FInd out how treatment turned their lives around.”